Early but not easy: recipients' experiences of alcohol-associated liver disease and early transplantation.

Alcohol-associated liver disease (ALD) is the leading indication for liver transplantation in the US,1 with rates of ALD and alcohol use disorder (AUD) being at epidemic levels.2 Six months of alcohol abstinence has been traditionally required before offering liver transplants for ALD; however, in recent years, many transplant centers in the US have been proceeding with liver transplantation when medically necessary for select individuals who don’t meet this requirement. Early liver transplantation (ELT) is linked to favorable clinical outcomes;3,4 yet, questions about candidate selection and equity remain.5 Furthermore, the perspectives and experiences of ELT have yet to be described despite the fact that they may differ from those who met traditional 6-month abstinence requirements.6–8 In this issue of Liver Transplantation, Chen et al9 describe the experiences of 20 ELT recipients with ALD from a single US transplant center who received ELT between 2012 and 2020. In a one-time qualitative interview, the researchers asked the recipients about their posttransplant challenges, relationships, alcohol experiences, and stigma. They then analyzed and summarized the data across 3 time periods, including the time before ALD onset, during severe ALD, and after the transplantation. Before severe ALD onset, the research-derived themes in this paper reflect ELT recipients’ experiences with alcohol use including loss of control over drinking, alcohol use negatively impacting relationships and other important domains of life, and alcohol use taking on a large and constant role in the lives of individuals. These themes map directly onto specific AUD diagnostic criteria, reflecting the experience of AUD in this population and underscoring the need for skilled addiction experts on transplant teams. While ELT recipients are characterized by a rapid onset of ALD, the precursor, AUD, can develop over years or decades, highlighting the need for upstream identification and intervention by addiction consult services, primary care doctors, and other health professionals. Innovative addiction-liver consultation and care models are other possible solutions to help fill this gap.10 When the individuals in this study developed advanced ALD, they described a very rapid decline in health and often lacked memory or awareness of key events before the ELT due to cognitive impairment. This raises ethical questions about the cognitive capacity and decision-making by patients and the veracity of the transplant psychological evaluation process itself, including whether predicting relapse after ELT is accurate. Perhaps, given the pressure of transplantation, coupled with an altered mental status and a compressed time course, predicting relapse in these acute settings is too fraught with errors to be reliable. Instead, the focus could shift to building posttransplant care models and assembling highly skilled interprofessional teams that can detect and respond to posttransplant relapse while accepting that such relapses will occur. After the transplantation, individuals highlighted the life-changing nature of the transplantation experience, including re-evaluation and re-organization of their lives and relationships with themselves, others, their work, and their alcohol use. Not all of this was positive as some individuals did not return to work and others experienced stigma and return to alcohol use. Others described worsening mental health and mood symptoms. However, many experienced deepening insights into AUD, connections with loved ones, and new and more positive outlooks and sobriety. This highlights how ELT and liver transplantation more broadly are psychosomatic processes and should be treated as such. Leveraging a transplantation event for psychological improvement and supporting long-term sobriety is an optimal goal for the patient, the donated organ, and the society at large. These experiences additionally highlight the need for robust posttransplant monitoring and readiness to take action when mood and mental health symptoms recur to prevent relapse and improve the quality of life. The extensive effort and research devoted to the pretransplant selection process must now be linked to an equally robust posttransplant system for surveillance and treatment of mental health and substance use warning signs when they occur. Taken together, this paper demonstrates that transplantation is secondary to the primary issue and process of AUD and recovery. Transplantation is not the end but one significant step toward a psychosocial goal—sobriety and a new way of living. Thus, supporting sobriety and a healthier way of living should be the goal of the entire transplantation experience, both before and after the transplantation itself. While alcohol use and relapse often dominate the discussion surrounding ELT for ALD, this study appropriately highlights the broader posttransplantation experiences of ELT recipients. ELT recipients felt high levels of gratitude for the “gift” of organ transplantation and saw the transplantation as a life-changing event. Many posttransplantation challenges were unrelated to relapse and included difficulties with personal relationships, loss of work or difficulty returning to work, and feelings of shame and stigma. While alcohol abstinence plays a central role in long-term survival and is a central consideration for the transplantation, it is important to highlight that relapse does not occur in a vacuum. Sobriety is more achievable when individuals have social support, treatment for psychological comorbidities, meaningful employment, and higher life satisfaction, and many of these themes stand out as central to ELT recipients’ well-being after transplantation in this study.9 Thus, as this paper points out, there is a great need for high-quality multidisciplinary, long-term integrated care to support those with ELT after transplantation. As has been stated elsewhere, the 6-month abstinence rule is an arbitrary designation and research highlights the need for flexibility related to this requirement.11,12 AUD is a chronic and relapsing condition, and no single length of abstinence guarantees a favorable outcome. ALD patients, like all AUD patients, are more likely to maintain abstinence and have better survival after transplantation with psychological and pharmacological treatment for AUD before and after the transplantation, positive social support, mental health treatment (when needed), economic stability, and safe living situations. Therefore, the best way to serve patients ethically and equitably includes not enforcing arbitrary abstinence requirements but offering ELT with clear and consistent candidate selection criteria coupled with high-quality multidisciplinary care that addresses their psychosocial, AUD, and medical needs both before and after the transplantation. Further research is needed to define what these optimal candidate selection criteria should be, but the present study represents an important step in the right direction by incorporating patient voices in the research on ELT.